Interventional Radiology Image-Guided Locoregional Therapies (LRTs) and Immunotherapy for the Treatment of HCC

Image-guided locoregional therapies (LRTs) are a crucial asset in the treatment of hepatocellular carcinoma (HCC), which has proven to be characterized by an impaired antitumor immune status. LRTs not only directly destroy tumor cells but also have an immunomodulating role, altering the tumor microenvironment with potential systemic effects. Nevertheless, the immune activation against HCC induced by LRTs is not strong enough on its own to generate a systemic significant antitumor response, and it is incapable of preventing tumor recurrence. Currently, there is great interest in the possibility of combining LRTs with immunotherapy for HCC, as this combination may result in a mutually beneficial and synergistic relationship. On the one hand, immunotherapy could amplify and prolong the antitumoral immune response of LRTs, reducing recurrence cases and improving outcome. On the other hand, LTRs counteract the typical immunosuppressive HCC microenvironment and status and could therefore enhance the efficacy of immunotherapy. Here, after reviewing the current therapeutic options for HCC, we focus on LRTs, describing for each of them the technique and data on its effect on the immune system. Then, we describe the current status of immunotherapy and finally report the recently published and ongoing clinical studies testing this combination.

Prostatic Abscess: A Review and Update

Prostate abscess (PA) is a complication that ensues an acute infectious purulent process within the prostate gland which is typified by accumulation of purulent material within the prostate gland and this purulent material could be unilocular or multi-septated within the prostate gland. PA is a rare disease especially in the developed world where PA tends to be more commonly associated with patients who have diabetes mellitus, chronic kidney disease, chronic liver disease, immunosuppressive disease, HIV Infection, renal transplantation, and long-term urethral catheterisation. PA tends to be more commonly encountered in the developing world. PA could be an acute abscess or chronic abscess especially in association with chronic inflammatory conditions including tuberculosis or intravesical instillations of Bacillus Calmette Guerin (BCG). PA tends to constitute 0.5% of all urology disease and 6% of all acute cases of bacterial prostatitis. The mortality rate associated with PA has tended to be between 1% and 16% of all cases of prostate abscess. PA tends to be most commonly encountered in individuals who are in their fifth to sixth decade and could occur at any age. PAs that are due to sexually transmitted organisms tend to be more commonly encountered in younger males. PA tends to affect the central zone as well as the peripheral zones of the prostate gland. Haematogenous dissemination from a primary source of infection from a primary infection elsewhere have been reported and some of the reported sources included respiratory tract, digestive tract, urinary tracts, skin, and soft tissue are very rare. PA has also been reported to be associated with staghorn calculus. Some of the reported bacterial organisms that have caused acute prostate abscess (APA) include: Escherichia Coli, Klebsiella, Pseudomonas, Proteus, Enterobacter, Enterococcus, and staphylococcus. Other causes of prostate abscess have included other bacteria and fungal infection including: Brucellosis, Salmonella, Nocardia, Mycobacterium tuberculosis. Prostate abscess has also been reported in association with malignancy of the prostate gland. Manifestations of prostate abscess could include: (a) systemic symptoms including pyrexia, chills, headache, general malaise, low back ache and in some rare cases of prostate abscess, a history of treatment for tuberculosis or contact with a person who has tuberculosis, or travel to a salmonella endemic area may be obtained and in cases of Brucellosis PAs drinking of raw milk / contact with animals may be elicited and or rare occasions treatment of superficial urothelial carcinoma with Bacillus Calmette Guerin may be elicited. (b) perineal pain, dysuria, urinary frequency, urinary urgency, retention of urine, recent prostate biopsy, visible haematuria, urethral discharge of pus, lower urinary tract obstructive symptoms with poor flow, intermittent flow, hesitancy, and sensation of incomplete emptying of the urinary bladder, retention of urine, and tenderness over the prostate gland with a feeling of bogginess and soft fluctuation. The symptoms tend to be non-specific. Diagnosis of PAs tends to be established based upon a good clinical history taking, good clinical examination, urinalysis and urine culture, routine haematology and biochemistry blood tests with evidence of raised white blood cell count and CRP and at times lymphocytosis in cases of tuberculous prostate abscess, blood culture, urine culture, PCR detection of sexually transmitted organisms, radiology imaging including trans-rectal ultra-sound scan of the prostate, or CT) scan of abdomen and pelvis including the prostate, or MRI scan of the prostate. Treatment of PA depending upon the size of the abscess has been undertaken with various options including: Appropriate antibiotic treatment alone for small abscesses based upon the antibiotic sensitivity pattern of the cultured organism, Antibiotic treatment and radiology image-guided aspiration of the abscess. Antibiotic treatment plus radiology image-guided insertion of a drain into the prostate abscess, trans-urethral incision / resection / modified resection of the prostate gland to deroof and drain the abscess, open drainage of the abscess is only undertaken on rare occasions. Within remote district hospitals in developing countries in the absence of radiology imaging, the clinician would have no choice but to undertake finger guided aspiration / drainage of the prostate abscess plus antibiotic treatment. It is important to obtain the culture and sensitivity result of the aspirated and drained pus so that if there are fungi cultured or rare organisms cultured the choice of antibacterial / antifungal treatment would depend upon the microbiology results. It is important to treat all complications urgently and appropriately including provision of intensive care. Careful clinical follow-up, laboratory investigations and radiology imaging are necessitated to ensure good recovery and to quickly identify as well as appropriately treat any recurrent abscess and on rare occasions if there is an associated prostate cancer it would be detected. The prognosis associated with the treatment of PA depends upon a number of factors including: Timely diagnosis and adequate and appropriate treatment of the PA. The underlying associated medical conditions of the patient. The prognosis tends to be good if the PA is diagnosed early as well as treated early including utilization of the correct anti-microbial medicament and appropriate drainage of the abscess. Poor prognosis tends to be associated with individual patients who are older than 65 years, fever with a temperature higher than 100.4 degrees Fahrenheit, benign prostatic hyperplasia, chronic long-term urethral catheterisation. In the scenario of non-availability of bacterial culture report in a remote area in a developing country when there is delay in getting the culture results from the regional or national centre there would be the possibility of utilizing a broad spectrum and potent antibiotics but if the organism is a fungus then there would tend to be recurrence of the abscess and poor outcome and for this reason it would be recommended that every hospital in the world should have access to good laboratory services including haematology, biochemistry, microbiology, pathology, and radiology services including ultrasound scan, computed tomography scan as well as magnetic resonance imaging scan as well as well trained staff to operative the various equipment as well as high dependency units and intensive care units and staff should be available to provide support for all patients that need support.

Arteriovenous Malformation of the Uterus: A Review and Update.

Arteriovenous malformation of the uterus (AVMU) is a very rare and uncommon condition, because it has been documented that less than 100 cases of AVMU have been reported in the literature. AVMU is potentially a life-threatening condition with regard to the fact that some cases of AVMU could manifest with profuse bleeding from the uterus via the vagina. AVMU could either be congenital AVMU which is less common or acquired AVMU with pregnancy noted to have a role to play in the pathogenesis of AVMUs. The true incidence of AVMU is stated to be difficult to ascertain in view of the fact that some cases of bleeding that have been caused by AVMU do tend to conservative, medical management and many of these AVMUs could remain undiagnosed. The most common manifestations of AVMUs tend to be abnormal uterine bleeding that could be episodic, intermittent, continuous, mild or torrential which could lead to severe anaemia or shock. Some AVMUs could be found incidentally based upon radiology imaging for a different condition. Other symptoms of AVMUs do include: Metrorrhagia; Menorrhagia; Bleeding following a miscarriage; Bleeding following dilatation and curettage; Bleeding subsequently after hysterectomy; Bleeding associated with trophoblastic disease; Bleeding following caesarean section; Post-partum haemorrhage; Intermittent vaginal bleeding; Continuous vaginal bleeding; Post-menopausal bleeding; Acute abdominal pain with hemoperitoneum; Pallor; Dizziness; Weakness; Drowsiness; Being unwell following delivery of a baby; Bleeding following therapeutic abortion; Tachycardia; Supra-pubic pain at times; hypotension. Diagnosis of AVMU tends to be made based upon radiology imaging with utilization of ultrasound scan / Doppler scan of the uterus and pelvis, Contrast Computed Tomography scan, and Contrast Magnetic Resonance Imaging Scan, as well as by selective angiography which tends to be ensued by treatment with embolization of the feeding vessels to the AVMU. The treatment of AVMUs these days has ranged between conservative and medical management that includes hormones for small AVMUs, Hysterectomy, which tends to be a definitive treatment that removes the AVMU but does leave the individual not being able to maintain her future fertility, as well as selective angiography and super-selective embolization of the uterine arterial branches feeding the AVMU, which does tend to maintain the future fertility of the patients and which has the advantage of being undertaken under local anaesthesia. Questions that should be on the minds of clinicians include should doppler ultrasound scan of the uterus be undertaken with regard to all women who develop persistent vaginal bleeding pursuant to or during management of miscarriage, considering that there are very few interventional radiologists in many hospitals. This means that selective angiography plus super-selective embolization cannot be undertaken in district hospitals should all women who have suspected AVMU that have severe bleeding that may require surgical operation be referred to a tertiary hospital so that they could possibly benefit from the undertaking of selective angiography and embolization of their AVMUs instead of hysterectomy to enable them to maintain their future fertility? It is also important for clinicians to be made aware of the existence of AVMUs so that they could appreciate the risk factors as well as the clinical manifestations who should be suspected of possibly having AVMUs. Clinicians also need to learn about various conservative and expectant methods of treating AVMUs including hormonal treatment. Clinicians also need to appreciate the future implications for future fertility of women who have AVMUs. Possible treatment options that have not been utilized for the treatment of AVMUs include: (a) Radiology image-guided cryotherapy of AVMU, (b) Radiology image-guided radiofrequency ablation of AVMU, and (c) Radiology Image-guided Irreversible electroporation of AVMU. There is a global need for the training of more interventional radiologists all over the world including in the developing countries as well as some of the developed countries to that they can undertake embolization of AVMUs as well as they can provide various interventional radiology treatment options for various other conditions.

Cast suppression in radiographs by generative adversarial networks

Injured extremities commonly need to be immobilized by casts to allow proper healing. We propose a method to suppress cast superimpositions in pediatric wrist radiographs based on the cycle generative adversarial network (CycleGAN) model. We retrospectively reviewed unpaired pediatric wrist radiographs (n = 9672) and sampled them into 2 equal groups, with and without cast. The test subset consisted of 718 radiographs with cast. We evaluated different quadratic input sizes (256, 512, and 1024 pixels) for U-Net and ResNet-based CycleGAN architectures in cast suppression, quantitatively and qualitatively. The mean age was 11 ± 3 years in images containing cast (n = 4836), and 11 ± 4 years in castless samples (n = 4836). A total of 5956 X-rays had been done in males and 3716 in females. A U-Net 512 CycleGAN performed best (P ≤ .001). CycleGAN models successfully suppressed casts in pediatric wrist radiographs, allowing the development of a related software tool for radiology image viewers.

Lung and Tumor Characterization in the Machine Learning Era

Danger characterization of tumors from radiology image container to be much precise and quicker with computer aided diagnosis (CAD) implements. Tumor portrayal via such devices can likewise empower non-intrusive prognosis, and foster personalized, and treatment arranging as a piece of accuracy medication. In this study , in cooperation machine learning algorithm strategies to better tumor characterization. Our methodological analysis depends on directed erudition for which we exhibit critical increases with machine learning algorithm, particularly by exploitation a 3D Convolutional Neural Network and Transfer Learning. Disturbed by the radiologists' understandings of the outputs, we at that point tell the best way to fuse task subordinate feature representations into a CAD framework by means of a diagram regularized inadequate MultiTask Learning (MTL) system with the help of feature fusion.

Basilar Artery Occlusion: A Clinical Radiology Image

A 48-year-old male patient with a history of hypertension presented to the emergency department unconscious and suspected to have a Cerebrovascular Accident (CVA). A plain CT scan was done which revealed old infarctions in multiple areas supplied by the vertebrobasilar system. The basilar artery appeared to be calcified, curved, dilated, and located outside the pontine groove. The CT scan shows occluded basilar artery see (the red arrow). The basilar artery was occluded because of the artery condition. The basilar artery occlusion is rare and it occurs in 1% of all strokes.

THE APPLICATION OF USING GEL PAD AS A MEDIUM FOR ULTRASOUND SHOULDER

Background: A conductive medium on ultrasound is a medium that is used to obtain sound wave transmission by minimizing air between the transducer and the skin. This study used materials that are easily found such as gel wax and paraffin for making the gel pad. A good oil and mineral based wax gel are used as a basic ingredient for ultrasound gel making. Gel pad can be used to minimize the structure of unauthorized organs. One of which is the shoulder. Objective: This study aims to determine the quality of the image in the use of standard gel, and the use of gel pad as a medium for ultrasound shoulder. Method: Gel pad is made by mixing gel wax and paraffin ingredients. This gel is used to obtain images from ultrasound investigation. The study used 16 samples with a total of 64 images obtained in which 32 images using standard gel and gel pad in the long axis position and 32 images using standard gel and gel pad in the short axis position. The analysis of image results is done using matlab image processing to assess SNR. The image quality obtained from the results of the questionnaire was assessed by a specialist in radiology. Image quality processing based on SNR was tested using independent T test. Meanwhile, the results of image quality from the questionnaire assessment were tested using Wilcoxon. Result: As many as 64 objects were obtained using standard gel. The gel pad showed that there were significant differences in the results of image quality based on SNR values. In the results of the questionnaire assessment, there are several anatomic organs that have no significant differences. Conclusion: The use of standard gel was still higher compared to the use of gel pad. The gel pad is able to become a standard gel alternative on ultrasound shoulder examination.

Vulnerability In Deep Transfer Learning models to Adversarial Fast Gradient Sign Attack for COVID-19 prediction from Chest Radiography Images (Preprint)

BACKGROUND COVID-19 pandemic requires quick isolation of infected patients. Thus high sensitivity of radiology images could be a key technique to diagnose symptoms besides the PCR approach. Pre-trained deep learning algorithms are proposed in several studies to detect COVID-19 symptoms due to the success in radiology image classification, cost efficiency, lack of expert radiologists and faster processing requirement in pandemic area. Such open-source models, parameters, data sharing to generate big data repository for rare diseases and lack of variation in the radiology image-capturing environment makes the diagnosis system vulnerable to adversarial attacks like Fast Gradient Sign Method based attack. OBJECTIVE This study aims to explore the potential vulnerability in the state of the art deep transfer learning models for COVID-19 classification from chest radiography image, to Fast Gradient Sign Method based adversarial attack. METHODS Firstly, we developed two transfer learning models for X-ray and CT image based COVID-19 classification from frequently used VGG16 and InceptionV3 Convolutional Neural Network architecture. We analyzed the performance extensively in terms of accuracy, precision, recall, and AUC. Secondly, we crafted the FGSM attack for these prediction models and illustrated the adversarial perturbation variation effect for this attack on the visual perceptibility of the radiography images through proper visualization. Thirdly, we computed the decrement in overall accuracy, correct classification probability score and total misclassified samples to quantify the performance drop of these models. The experiments were validated using publicly available COVID-19 patient data. RESULTS We collected publicly available, labeled 268 Xray and 746 CT images. The performance of the developed transfer learning models reached above 95% accuracy with F1 and AUC score close to 1 for both X-ray and CT image based COVID-19 classification before the attack. Then our study illustrates that the misclassification can occur with a very minor perturbation of 0.009 and 0.003 for the FGSM attack in these models for Xray and CT images respectively without any effect on the visual perceptibility of these images. In addition, we demonstrated that successful FGSM attack can decrease the accuracy by 16.67% and 55% for Xray images and 70% and 40% for CT images while classifying using VGG16 and InceptionV3 respectively. Finally, the correct class probability of any test image is found to drop from 1 to 0.24 and 0.17 for VGG16 model for Xray and CT images respectively. CONCLUSIONS Frequently used chest radiology based COVID-19 detection models like VGG16 and InceptionV3 can significantly suffer from FGSM attack. Extensive analysis of probability score, misclassifications, perturbation effect on visual perception clearly illustrates the vulnerability. The InceptionV3 model is found to be more robust than VGG16 although FGSM can make them vulnerable. Thus despite the need for data sharing and automated diagnosis, practical deployment of such program asks for more robustness.